Vauxhall jury findings
 

"Mr Barnes, a pilot of 24 years, was under great commercial pressure to satisfy an important client that morning when he made the flawed decision to fly, which was "neither safe nor appropriate", the inquest heard. "

Full report:

Vauxhall helicopter crash deaths 'accidental' jury finds - BBC News

The key lesson is very clear, if a little harsh:


You are the captain

Your are responsible for the safety of the aircraft, crew, passengers and folk on the ground


It is your decision - alone - whether to light the burners and lift


"Commercial pressure" does not change anything of YOUR responsibility. If you can't stand up to the nasty rich man and take both the decisions and the responsibility for those decisions, then you should not be in the captain's seat. Take the fancy-dress cabbage off your shoulder, stop masquerading as a "captain", and get out of the seat before you kill yourself and others.

JohnR81

Well put !

John R81

Your proposition is broadly correct, despite the childish language in your final paragraph .
It's also very easy for a PPL to say.

To their great credit, the jury didn't adopt such a simplistic approach.
They identified a very real problem - which sooner or later, preferably sooner, needs to be addressed.

We all know in broad terms what happened. Much more important is why it happens and what can be done to reduce the risk of it happening again. Until those issues are addressed, such accidents will continue.

The pilot's decision is, of course, final.
In practice, as history shows, it is not as simple as that.

(I note also that the jury clearly didn't accept the client's version of events.)


SASless I can imagine Pete saying that but, having known him for many years and having flown with him several times, I have no doubt whatsoever that he didn't mean it literally. I believe it was part of his 'client PR' - to ensure the client understood that he was doing his best.

07:53 Pilot to Client: "Hdg back to Redhill least we tried chat in 10"
(He had abandoned his attempt to collect the client and was returning to base. He had already told another witness this two minutes earlier at 07:51)

Then came:
07:55 Client to Pilot: "Battersea is open."


If only that message had not been sent ......

Client pressure is addressed.....Weekly by Ops staff and pilots.

Ironically I've said 'no' twice in the past seven days to people that gave evidence at that inquest 😢. A 'no' fully supported by my CP and Ops.

I was one of several that cancelled flights that morning. Pete was a friend, but the buck 'stops' with us as individuals and an industry.

This industry doesn't need tighter/more rules. It needs the white knuckle companies that SND describes addressed. It needs more CPs like/with the oversight attitude of SND (albeit the Planet isn't really big enough for two of him 😉).

Yes, it would have been better if the final sms hadn't been sent. Equally we wouldn't be discussing this if nobody 'had tried'.

Yes. Prior to that, Pete had elected to RTB. The customer was trying to be helpful, and from his remarks, that came up earlier in the thread, I'm sure no pressure to go to Battersea was intended, but in Pete's mind, it was probably implied. :(

Could just as easily been a wealthy PPL trying to pick up a mate to go and poop off some shotguns? You live in London, just how out of reach is a 109 and an IR? Private pilots like DR or JP suggest not at all, so CPL, PPL, ATPL don't seem to be the barrier to having an accident.

In the UK we have arguably the most mature aviation structures in terms of regulatory, industry and aeronautics. From the CAA, AAIB, RAeS, BHA, The Honourable Company of Air Pilots etc. Not only do these groups have huge experience as a whole and individually but a great many have members that crossover. The point being that if we wanted to resolve this issue we could do.

The CAA has broadened the scope of its response to SR2014-35 to a "broader and deeper review of IFR flying outside of controlled airspace". It was due for completion Oct 1. One assumes that part of that review could go some way to have given a more formalised structure to contain client pressures?

The inquest heard this:-

Whilst the captain he wasn't a director or shareholder of Rotormotion UK nor did he own the helicopter so from a business perspective so there were at least two other parties with bigger commercial interests.

Yet where are Amadeus's ownership of the issues and view on the flight on that day? Given he was also the owner/director of the company. Whilst perhaps no actual rules get broken but it just feels shabby as it seems the company let PB dangle.

One very easy way to get a solution to this is make any communication to aviation businesses, (be that pilot/customer to pilot, pilot/customer to ops) such as this on recorded telephone lines. Beyond that it wouldn't be difficult to make sure any customers with a high % of total company revenue are controlled. There should be no space for the "I'll leave it up to you".

Sounds a sensible idea!

So the inquest has completed before that review. Will it suddenly emerge in the last days before Christmas?

Unfortunately Pete was under a lot of pressure that day but I feel the majority was self induced.
The client hit the nail on the head when he said "Maybe part of the fault is that we became too friendly and he thought he would be letting me down." Anyone who knew Pete would understand this but it does not justify the outcome.

I will wait with interest to see what pressures were involved in the Norfolk accident, lets see if that can of worms is fully opened.

Are the Chief Pilots/Managing Directors of helicopter companies, and private owners without a CPL/ATPL who employ a pilot(s), ever vetted by the CAA to assess their attitudes to rules and flight safety? If not perhaps they should be ......

My language in last post was carefully chosen, and I stick to it. Childish? perhaps, from your viewpoint; but a clear statement of how I personally feel towards anyone who will not stand-up to "pressure" when it is their clear responsibility to do so.


Easy for PPL to say? Well.....


Aviation is not the only profession in which clients might want to do things that are close to the line, on the line, or even over the line. For a self-employed person (I am - a large professional partnership) there is financial pressure not to lose the client, and for employees in some businesses there can be management pressure not to disappoint the client on pain of perhaps loosing their job. So I simply don't see this question being any different in the field of commercial aviation. In my own field, junior employees with poor judgement don't get promoted to be seniors employees. Senior employees who have not actually displayed positive good judgement don't get to be admitted as Partners.


The captain has responsibility for the flight. Take that responsibility or don't be captain. Yes, it's simplistic but it will prevent further deaths.

^^

I completely agree with this and I was in professional aviation for 27 years, including 3 years in a flight authorization role.

Latterly I have been a director in two other industries, the current one of which is subject to every bit as much "compliance" as aviation. The mistake that is made is to view aviation as something special and John R81 does us a favour when he points out the human failings do not recognize the "specialness" (for want of a better word) of any given profession.

Certain professions confer certain absolute responsibilities - as Truman famously put it "the buck stops here". Aircraft Captain is one such, however simplistic that might appear. I am of course well aware of the myriad complexities of Human Factors (as I said - three years in flight authorisation - ie I authorised the captains). The whole point of any training/authorisation process is to ensure that on the day the captain makes the right call.

Sometimes they don't. And from that we should all learn. Blaming the client, or the director is not learning.

It's denial.

Amen to that, but I'm curious to know what people think the solution is. Two pilots ? erm.. LBAL. Individual flight risk analyses ? erm... this flight went wrong when it went off piste. More and different people being involved in the Go/Nogo decision ? erm... really ?

I think Nick Lappos was beginning to explore the right track with his atttempt to bring landing aids and lightweight instrumentation to the mainstream helicopter world. If you updated his work to include current technology for synthetic landing aids you'd really be getting somewhere. But even then the fixed wing world manages its fair share of cock-ups even with their runway to runway IAP driven approach to IFR.

If you then extended this idea to a drone like world (think "minority report") where the normal operation of a flight was entirely automated, then I think you'd really be getting somewhere. You could then either relax and accept that the only problems now would be unmanaged system failures, or put a pilot in there with strict instructions not to touch the controls unless something went wrong.

On second thoughts, scratch that second idea.

Couldn't resist posting this little extract of ALL the serious incidents from the Docklands Light Railway Wikipedia entry since its inception in 1987.

Overrun of station buffers
The original Island Gardens DLR station at the end of a viaduct

On 10 March 1987, before the system opened, a test train crashed through buffer stops at the original high-level Island Gardens terminus and was left hanging from the end of the elevated track. The accident was caused by unauthorised tests being run before accident-preventing modifications had been installed. The train was being driven manually at the time.

Collision at West India Quay bridge

On 22 April 1991, two trains collided at a junction on the West India Quay bridge during morning rush hour, requiring a shutdown of the system and evacuation of passengers by ladder.[117][118] One train was travelling automatically, while the other was under manual control.

South Quay bombing

On 9 February 1996, the Provisional Irish Republican Army blew up a lorry under a bridge near South Quay,[120] killing two people and injuring many others.[121] The blast caused £85 million of damage and marked an end to the IRA ceasefire. Significant disruption was caused and a train was stranded at Island Gardens, unable to move until the track was rebuilt.

The bit that got Pete (and has got many others before) is that he forgot that his prime role was that of safety mechanism. We've all been there, being too closely linked to business imperatives. In its simplest form it is the chief pilot questioning why a standard route took 0.6 instead of 0.5.

This morning is an example. Wx is crap and the forecast told us that yesterday. So, why are punters still hanging around on a 'maybe'? There are many operators who will stare at an optimistic PROB 30 TEMPO and encourage their pilots to launch into the ether. The problem with that is the business pressure has now been put fair-and-square on the pilot. It takes a strong operator to make the sensible decision before the problem even reaches the pilot; many prefer to hide behind their ops manuals. :hmm:

R81 - well said overall. I say overall, because the act of turning your client down could mean losing your job and that puts an enormous amount of pressure on LESSER men/women, I would suggest.
I'm not saying it's an easy decision, I'm saying perhaps the solution is to pick your employment carefully perhaps.

My biggest beef - having experienced it countless times (and the ops director for MCAlpine Helicopters/Premier was notorious for saying this when he was in the game years ago - is that the threat by these people on their pilots generates rule breakers and ultimately professionals who go 'rogue'. It is these pilots who will do it if another won't and it is they I wish to pass this message:
You are letting yourself down and your profession down every time you accept a borderline job, simply to keep your job. Plan ahead and the next time you apply for a corporate job - check out the client - it's a two way interview you know.

Even more reason to do this if you have a partner / kids FFS.

No arguing...being helpful and perhaps directly informative to one or two less worldly wise....

Disclaimer...this advice applies specifically to the UK, although it will apply equally in most other Western jurisdictions.

It is unlikely you would lose your job for doing your job correctly for two reasons:

1. Even in aviation, most people who get to own/run companies are not actually dumb, however much they give the impression that they might be. People who own/run companies are well aware that good staff are - literally - worth their weight in gold and they will look after them as such...even if they don't get along.

2. Assuming your employee has worked for you for two years, if you fire them without good reason, and without following employment protocols, you are bringing a sh1tstorm down on your company. Any employee in the UK that allows themselves to be fired without cause and does not head straight for the nearest employment lawyer is basically ****ing nuts.

For most human beings firing someone is extremely traumatic (trust me...been there, done that). I am an occasional business mentor and one of the commonest failings in business is directors/owners NOT firing people that it is glaringly obvious they should.

So don't be scared of ghosts under the bed...they are usually not there.

Getting all legal because you are not employeed will really depend upon how your services are being engaged in the first place. If you want to specifically relate it to this accident I doubt that PB was an employee of Rotormotion UK in a PAYE sense, meaning there are few (if in fact any) employment laws that would protect.

Given his piloting services were used elsewhere that would be an expensive way to be employeed for a variety of reasons. That said his logbook hours suggest his ability was such that he didn't need to worry about that too much.

What we are all missing when we talk of this pressure is that it isn't recognised to a level that requires any action because there was no safety recommendation in this regard and so if the inquest concludes client pressure was fundamentally the cause of this accident it differs from the AAIB.

Freelance pilots (as many helicopter pilots are in the UK) are not well placed to take legal action if their work from a particular source dries up.

Their 'employer' in many instances is the company they have set up for the tax advantages.


Pitts

Not recognised to a level that requires any action in the opinion of the AAIB doesn't mean the problem doesn't exist.
I concede it's arguable that the very small number of incidents/fatalities is insufficient to justify any action, and that the solution isn't immediately obvious - at least to me.

Yeah agree with all of that although isn't it surprising that the commercial elements, as they may have related to the decision to fly, were not fully investigated (or at least not reported) especially since the body of work done took circa 20 months.

When you reflect upon the conversation about PB transferring to biz jets, that the client had interest in the same, that there had been recent issues to a degree that only PB and the owner of RMUK were to fly this client. The lack of detail that relates to the process of decision making specifically with this flight, including the pre flight conversation with the CP, especially as it is specifically referred to in the ops manual and is no doubt required by the ultimate owner of the machine and its insurance.

We don't find any of that a concern or a need to improve?

It's barely believable that the investigation can go into so much detail about the physical structure that ultimately ended the flight whilst skimming across the human factors that put the machine in the air in the first place.

The lack of an AAIB safety recommendation may not mean that further issues do not exist but having one at least puts it squarely on the table and communication of response and follow up actions are visible.

Well we have turned down work today in marginal weather, could do with the monies but ones life is for more important. Have discovered over the years with regular customers they are much more interested in you being honest especially when it comes to safety. In fact have gained customers due to this attitude rather than loose them. More than happy to tell a customer where to get off, years ago I put down in a field due to weather being considerably worse than forecast. Customer complained so i gave him the keys and said help yourself. Needless to say machine stayed in field. Taxi called customer arrived safely still on time !

Same here but it's interesting to see how different brokers react. Some, who one would have thought should know better, still get rather forthright. :=

Read through the AAIB report again last night.


Pitts - personally I don't see an issue with human factors that caused the aircraft to take-off that morning. It was reported 999 at EGKR and expected to remain so. In that machine, VFR on-top under Radar control, was not unsafe. The decision to abort overhead EGTR and RTB was sound, and initially executed without additional risk. The flight back was uneventful to begin with and would have remained so (EGKR approach and landing were not hampered by Wx) if the plan had not changed.


We can't - and shouldn't - exclude humans from the equation and no amount of "rule creation" or "kit solution" will do that. There is always a balance between risk and other matter and only a human will make those complex decisions. As many have noted, simply saying "pilot error" does not help prevent recurrence, and so more analysis is needed. With the benefit of hindsight we can identify decisions that now look to be unwise and so the pertinent human factor question is: why did those decisions at the time look to the pilot to be the most appropriate responses given the information held and the options realistically available?


Carrying on with the flight sequence, this is where it seems to me things began to go wrong:


1. Getting a text to say EGLW was open - relevant as it presented an option not planned & prepared for. It would add pressure to check the information and to plan approach, etc. It would also allow for distraction of thought to what subsequently would happen - quicker response time to pick-up the client once the Wx improved - and hence add to the factors weighed in making the decision whether to continue RTB or to divert. Options at this moment were to respond that cloud was too bad to get through, or to try use resources to plan / execute the divert if it is available.


2. Asking LHR Special for confirmation that EGLW was open and would accept the landing. Given location, speed, etc this put time pressure on the task of getting below cloud but the option was to orbit above cloud whilst the matter was researched and reported back.


3. Deciding to drop through a "sucker hole" to get below cloud rather than orbiting.


4. On getting below cloud, finding the base to be very low in a flight environment filled with obstacles, continuing with a "normal" approach; flying the dog-bone holding pattern. Options at that time include going straight back up and rejecting the diversion, or alternatively going into a (noisy) OGE hover over the river.


5. Possibly being distracted (radio frequency change, for example) whilst executing a more challenging manoeuver in conditions that were certainly less than ideal; option of completing one task before commencing another.




Interested to learn if others agree that the relevant chain of events starts where I put it or somewhere else. I agree that prior interaction with the client, with other clients and with management are relevant to the decision process in accepting / attempting / rejecting the diversion. Also interested to hear if others see more "decision points" in the sequence.




Based on my interpretation (valueless, as I am neither an AAIB investigator nor a lawyer), the verdict of the inquest was not accurate as it cites perceived client pressure and Wx in relation to the decision to lift from EGKR. I suggest above that there was no safety problem with that decision or with the decision to RTB. The perceived client pressure was a factor in the decision to divert to EGLW and I would have liked to see both the AAIB and the inquest to have focussed more on the human factors that led to that decision, and to subsequent decisions once the descent through the sucker hole commenced.

An excellent question, to which the answer must be that wetware tends to make bad decisions under pressure.

If Pete had been making the decision about going to Battersea on the ground he would have taken a lot more factors into account. He might have thought, the client is in Elstree and the weather is clear back at Redhill and towards our ultimate destination in the North of England. It will take the client 90mins or so to get to Battersea from Elstree by car at this time of the morning. In 90 mins by car from Elstree he could be at Redhill or Luton or Cranfield, the latter two of which have precision instrument procedures. Even if he still wants to go to Battersea, flying to Redhill and waiting is cheaper than parking at Battersea. After discussion on the phone about which of these options suits the client best, he could have finished his tea, had a bacon sandwich, and leisurely initiated his new plan.

So the trick is to give yourself time and options, neither of which are available in the air in highly congested airspace in bad weather.

Getting a text to say EGLW was open - relevant as it presented an option not planned
 

I have said this before on here and I will say it again untill the cows come home, Battersea was not open.
I recieved a call from the DATCO, Requesting if we would open and accept a diversion from SVFR/Thames Radar, To which I gave autherisation.
It was upon this autherisation that the DATCO tried to contact the Pilot, alas with no response!

We know that you've posted the same information on this forum several times.

Can you please explain to us why you didn't share this information with either the AAIB or the subsequent Inquest?

CD and B73: is that the right question? I think that strikes to "why did X send a text to the pilot saying Battersea was open when in fact it was not open?".


From the point of view of the pilot, it seems that he received a text saying Battersea was open. Even if that was factually incorrect, he pilot did not know that and he proceeded to act upon that information by asking Thames Radar about the option of diverting, and dropped down below the cloud-base to hold below in anticipation of being accepted into Battersea.


Puntosaurus: Thanks - I think this is a valuable point for me to take on board. It is a different matter to plan for diversions whilst on the ground compared to an environment of congested airspace / bad weather / client pressure. Though circumstances may make that scenario unavoidable, I need to be conscious of the need to take steps to reduce my workload and risk if I am to divert resource (my attention) to assessing / planning the diversion. I can make that part of my rehearsed response to in-flight "surprise".

John R81;

We see Battersea is open/closed as pilots. In similar conditions to the day Pete Barnes crashed (but a couple of years before) I had a passenger tell me that he had spoken to Battersea and they were open, and why was I refusing to fly? In my case Battersea was open, the problem was the LHR/LCY weather meant we would not have been able to legally get into the zone. Trying to tell a pushy passenger that yes, Battersea was open, just as reception had told him, but that the weather passed to me by Battersea ATC precluded landing there seemed utterly beyond the grasp of such an intelligent man.

If Pete's passenger had spoken to Battersea, I suspect he would have spoken to reception NOT ATC. Yes Battersea was either open, or about to open following all the checks, and certainly was open for passengers to sit and drink coffeee in the lounge while their pilots waited for the weather to clear enough for them to get in, that did not constitute a confirmation that the weather was suitable. Its a question of semantics, to Cave Dweller (who really does know his stuff) Battersea was closed to air traffic, 60 metres away in reception to the guys and gals who look after the pax and take all the bookings and phone calls from customers etc Battersea was definately open.

The passenger sends a text saying Battersea open from his limited level of knowledge, the meaning to the pilot is different. A box 2 call to Battersea could possibly have sorted the confusion, but we will never know.

SND

John R81 has made a lot of sense on this topic, and Puntosaurus' point on why did PB not divert to say Luton is a good one, given a northern destination. Would be quite interesting to know what the EGGW METAR around the accident time was - anyone know? May well have been fogged in too though I guess. Of course not just cost but the faff of a big airport is often another reason to try to avoid them.

Something that seems missing from (what we know about) the accident flight was what contingency plans were discussed between client and pilot/operator, given the high chance that a landing at the Elstree pick up point would not be possible. Where was the client based? Was Elstree the best place to plan for the pick up? Could Redhill have been considered an option where departure would have been possible in far poorer weather than a landing? Was Luton considered as an alternate? Stansted? Wx info was probably not available at Cranfield early enough. These human factors aspects are important and can greatly add to the risks.

Frankly I doubt PB was really pressured into flying - surely he was too experienced and confident for that. But he would have simply wanted to get the job done and not let his client down, so pushed himself too far.

Pressure, whether from clients, operators or from we pilots ourselves, to get a task done is a risk factor. But it is an inevitable part of flying (and a lot of other things) and to an extent healthy, to encourage us to look at ways of achieving (albeit safely) a flight when conditions are more challenging.

I think something that does come out of this accident is the importance of considering very carefully the alternative options, in advance when on the ground, should the weather compromise or prevent the flight. And these options should be discussed with and ideally agreed by the client, and perhaps even conveyed in writing, by text or email. That might help reduce excess pilot pressure and make clients consider alternatives more carefully and make plans for such eventualities. Obviously I'm sure much of this all happens with good operators anyway, though it appears not have done here and had it occurred, the accident would probably have been avoided.